ARTICLE IN PRESS

Respiratory Medicine (2007) 101, 363365

CASE REPORT

Subcutaneous emphysema secondary to pulmonary

cavity in absence of pneumothorax or
pneumomediastinum
Deveshwar Pandey, Pramod Jaret, Rajesh Sharma, Amit Sharma,
Surinder Thakur
Department of Medicine, Indira Gandhi Medical College, Shimla 171001 (H.P.), India
Received 18 March 2006; accepted 26 April 2006

KEYWORDS
Subcutaneous emphysema;
Pneumomediastinum;
Air leak

Summary Subcutaneous emphysema is a common condition occurring after chest

injury. It may also be observed in association with pneumothorax or pneumomediastinum as a result of pathological changes in the respiratory tract. Spontaneous
subcutaneous emphysema in absence of pneumothorax or pneumomediastinum is
rare. We report a case of spontaneous subcutaneous emphysema in isolation
secondary to fibrocavitatory lesion in the chest along with review of the literature.
& 2006 Elsevier Ltd. All rights reserved.

Introduction

Case report

Subcutaneous emphysema is not an uncommon

condition complicating blunt or penetrating trauma
injury to laryngeal, tracheal, or bronchial tree. It
may occur following chest tube insertion or
tracheal intubation. Rarely, this condition has been
observed as a result of pathological changes in the
respiratory tract. We present a case of spontaneous
subcutaneous emphysema in absence of pneumothorax and pneumomediastinum in a patient
with pulmonary fibrocavitatory disease secondary
to pulmonary tuberculosis.

A 60-year-old male, labourer by occupation,

presented with complaints of pain on right
side of the chest, sudden in onset after a bout
of coughing yesterday. It was followed by
swelling over upper half of the chest, more on
right side, spreading to neck and face over 6 h.
There was no history of trauma, retrosternal
pain, or shortness of breath. Patient had a history
of productive cough for the past 1 month
with sputum that was odourless, white colored
with occasional streaking of blood. Patient had
smoked for the past 20 years and had a history of
pulmonary tuberculosis for which he was treated 3
years ago.

Corresponding author. Tel.: +91 9816 072 444.

E-mail address: surindersml@yahoo.co.in (S. Thakur).

0954-6111/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rmed.2006.04.024

ARTICLE IN PRESS
364

D. Pandey et al.

On examination, patient was conscious and

oriented. There was swelling over the face, neck
and upper half of the chest (Fig. 1). Pulse was 84
beats per minute, regular and blood pressure was
140/80 mm of Hg. JVP was not raised. There was no
lymphadenopathy. On examination of the chest,
there were no dilated veins. Crepitus was present
over the chest and neck on palpation. There was no
evidence of mediastinal shift. Review of other
systems was unremarkable.
Investigations revealed hemoglobin of 13 g%,
total leukocyte count of 8500/mm3, differential
leukocyte count showed polymorphs 61%, lymphocytes 32%, monocytes 3%, eosinophils 4% and ESR
120 mm in 1st hour. Serum biochemistry was within
normal limits. Sputum for AFB was positive. Chest
X-ray revealed fibrocavitatory changes in right
upper zone with subcutaneous emphysema in the
chest and neck (Fig. 2). Computed tomography (CT)
of thorax revealed diffuse subcutaneous emphysema with cavity in right upper lobe communicating
with right main bronchus and subcutaneous tissue
with consolidation in bilateral lung fields (Fig. 3).
There was no enhancement after I.V. contrast in
these lesions. Patient was treated with high flow
oxygen along with ATTCategory II regimen. There
Figure 2 Chest X-ray revealing fibrocavitatory lesion in
the chest with subcutaneous emphysema in the chest and
neck.

Figure 3 Plain CT chest showing broncho-cavitatorysubcutaneous fistula.

was slight decrease in swelling and patient was

discharged on request.

Discussion
Figure 1 Subcutaneous emphysema involving the chest
wall, face, neck, and eyelids.

The escape of air into subcutaneous tissue is

known as subcutaneous emphysema. It is termed

ARTICLE IN PRESS
Subcutaneous emphysema in absence of pneumothorax
traumatic if secondary to either blunt or penetrating external injury. The term secondary spontaneous subcutaneous emphysema is used where the
leakage of air has arisen as a result of a recognizable coexisting structural abnormality in the lungs.
Subcutaneous emphysema involving face, neck
and upper chest may mimic edema as in nephrotic
syndrome, allergic, or angioneurotic edema. However, it can be easily diagnosed by the crunchy
sensation and crepitation on palpation. Among the
various theories analysed by Bloomberg,1 preexisting weakness of either the alveolar or bronchial
wall exists. The increased intrapulmonary pressure
because of excessive and prolonged coughing
causes rupture at a weakened point allowing
escape of air in the tissue. Air escapes via
peribronchial or perivascular channels to the
mediastinum. In the mediastinum, air spreads into
loose alveolar tissue, which can then enter into the
neck and subcutaneous plane in all directions. Neck
and chest wall are the usual anatomical locations of
the subcutaneous emphysema, though rarely scalp,
palm of the hands, soles of the feet may be
involved.2 Subcutaneous emphysema in the absence of pneumomediastinum or pneumothorax is
rare, which makes our case interesting.
Pulmonary tuberculosis is a common condition
complicated by air leaks. Most of the cases
reporting air leaks are as a complication of miliary
tuberculosis. Spontaneous pneumomediastinum associated with pulmonary cavitation has been
reported by Qureshi,3 but pulmonary cavitation
complicated by subcutaneous emphysema without
pneumothorax or pneumomediastinum has not
been reported to the best of our knowledge.
Besides tuberculosis, staphylococcal pneumonia,
measles, pneumocystis carinii, influenza pneumonia and pertussis are other infections causing
subcutaneous emphysema, especially among children.4 It has also been reported as a complication
of asthma with inhaled bronchodilators and nebulisation as an additional risk.5,6 Air is occasionally
drawn into the fascial planes of the mediastinum
from wounds in the neck, including tracheostomy
and surgical procedures in the mouth, pharynx and
upper gastrointestinal tract.

365

Radiological studies are essential to diagnose the

primary cause and the extent of air leak. To
diagnose pneumomediastinum, routine lateral view
along with posteroanterior view should be taken, as
50% of cases that would otherwise be detected on
lateral view may be missed.7 CT is helpful in the
diagnosis as in our case, broncho-cavitary-subcutaneous fistula leading to subcutaneous emphysema
was demonstrable on CT.
Subcutaneous emphysema carries no particular
risk of its own. In most instances treatment is
palliative and consists of treating the underlying
disease and prevention of further air leak. Subcutaneous emphysema is self-limiting and resolution of the air leak occurs by resorption of aberrant
air. However, the primary cause and the associated
intra-thoracic air leak such as pneumothorax,
pneumomediastinum or pneumopericardium may
lead to serious complications. In such instances,
therapeutic efforts are directed to the primary
condition and associated intra-thoracic air leak.8
Patients with respiratory distress and hemodynamic
instability may need tracheostomy and skin incisions over the neck and anterior chest wall.

References
1. Bloomberg WM. Generalized non-traumatic subcutaneous
emphysema. Can Med Assoc J 1927;17(3):3368.
2. Narchi S. Fever, facial swelling and dyspnoea. Int Pediatr
2003;18(2):924.
3. Qureshi SA. Spontaneous mediastinum associated with pulmonary cavitation. Postgrad Med J 1980;56:489.
4. Das M, Natchu UCM, Lodha R, Kabra SK. Pneumomedistinum
and subcutaneous emphysema in acute miliary tuberculosis.
Indian J Pediatr 2004;71:5534.
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accumulation as a complication of pneumomediastinum and
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